PATIENT INTAKE FORM. Name: Address: Town: State: Zip Code: MMJ Card #: Exp. Date: Drivers License #: Exp. Date: Home Phone: Cell:

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1 PATIENT INTAKE FORM Name: Last Name First Name Date of Birth: / / Gender: Male Female Address: Town: State: Zip Code: MMJ Card #: Exp. Date: Drivers License #: Exp. Date: Home Phone: Cell: Primary Care Physician: MMJ Certifying Physician: Registered Caregiver (if applicable): Phone #: A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary. If you feel that you need a caregiver, please contact your certifying physician. Are you a veteran? (Please check one) Yes No *IF YES, PLEASE PROVIDE DOCUMENTATION* 1.

2 Qualifying Condition: Patients 18 years of age or older: Amyotrophic Lateral Sclerosis Cancer Cachexia Cerebral Palsy Complex Regional Pain Syndrome Crohn s Disease Cystic Fibrosis Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity Epilepsy Glaucoma Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity Multiple Sclerosis Parkinson s Disease Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome Post Laminectomy Syndrome with Chronic Radiculopathy Post-Traumatic Stress Disorder Sickle Cell Disease Severe Psoriasis and Psoriatic Arthritis Terminal Illness Requiring End-of-Life-Care Ulcerative Colitis Uncontrolled Intractable Seizure Disorder Wasting Syndrome Patients less than 18 years of age: Cerebral Palsy Cystic Fibrosis Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity Severe Epilepsy Terminal Illness Requiring End-of-Life Care Uncontrolled Intractable Seizure Disorder 2.

3 Tobacco use? Yes No Alcohol use? Yes No Cannabis usage? Yes No Please describe, if Applicable Have you had any negative cannabis usage effects? Have you had positive cannabis usage effects? Negative symptoms that I am currently experiencing: (Please check all that apply) Abdominal Pain / Cramping Anxiety Depression Difficulty Remaining / Falling Asleep General Pain Headaches Irritable or Hyperactive Bowels Muscle Pain / Stiffness Nausea / Vomiting Nerve Pain Ocular Pressure Opiate Dependence Poor Appetite Seizures Tremors Other Health Conditions: Allergies: Current Medication: Dosage: Provide List or write on back if additional space is needed 3.

4 What outcomes do you hope to experience using medical cannabis? What method of medical marijuana do you prefer? (Please check all that apply) Smoking Vaporizing Edibles Oils Tinctures Concentrates I am uncertain Type of medicine preferred? (Please check what applies) High THC Low THC High CBD Low CBD 1:1 Ratio THC / CBD I am NOT sure of my medical needs Preferred Medical Marijuana Products used currently, if any: As a patient of Caring Nature Dispensary: PRIVACY POLICY AND PRACTICES I understand I have rights to privacy of my protected health information as defined by the Health Insurance Portability Act of I have been made aware that upon request a copy of Caring Nature s privacy policy is available to me. Caring Nature has made me aware of their right to change the terms of its Notice of Privacy Practice Patient Signature Date Authorized Patient Representative 4.

5 Relationship Signature Date FOR OFFICE USE ONLY I was not able to obtain patient or patient representative signature. Employee name Date Reason MEDICAL CANNABIS ACKNOWLEDGMENT OF DISCLOSURE AND INFORMED CONSENT Please be advised of the of the following: Possession or use of this product is unlawful outside of the State of Connecticut Cannabis-based medicine may have intoxicating effects and has not been analyzed or approved by the united states Food and Drug Administration and was produced without FDA oversight for health, safety, or efficacy. Medical cannabis may contain unknown quantities of active ingredients, impurities or contaminants. The efficacy and potency of cannabis may very widely depending on the cannabis strain and ingestion method. If the cannabis is smoked or vaporized: Smoking may be hazardous to your health. Cannabis smoke contains carcinogens and may lead to an increased risk of cancer, tachycardia, hypertension, heart attack, birth defects, brain damage, and lung disease. 5.

6 If cannabis is eaten or swallowed: This product has been infused with cannabis or active compounds of cannabis. When eaten or swallowed, the intoxicating effects of this drug may be delayed by two or three hours or more. There is limited information on the side effects of using cannabis, and there may be associated health risks. Side effects of cannabis can include, but are not limited to: Memory loss Dry Mouth Sexual Impotence Low blood pressure Confusion Hunger/Loss of appetite Cough/Bronchitis/Shortness of breath Depression Feelings of euphoria Drowsiness/ Fatigue/Abnormal Sleep Sedation/slower reaction time/inability to concentrate Suppression of immune system Anxiety/Nervousness Irregular/Increased heartbreak Numbness Agitation Poor physical condition Dizziness/Impairment of motor skills Dependency Impaired vision Laryngitis/Bronchitis/General Apathy Headache/Nausea/Vomiting Paranoia/Psychotic Symptoms Symptoms of cannabis overdose include, but are not limited to, nausea, vomiting, and disturbances to heart rhythm. This acknowledgment of disclosure is to advise you of risks and side effects of using cannabis medicines. It is important you review this document and discuss any questions you may have with the dispensary pharmacist. Please do not sign this agreement if you do not understand the information you have received or not comfortable with the risks that may be related to cannabis use or possession. Patient Signature Date 6.

7 MEDICAL CANNABIS PATIENT AGREEMENT I agree that the following statements are true and accurate: I am over 18 years of age and I am registered with and understand the requirements of the State of Connecticut s medical marijuana program. I agree to strictly comply with the regulations, terms and conditions of the State of Connecticut s medical marijuana program. No cannabis obtained by me shall be used for any other purpose than as directed by my certifying physician. I understand cannabis is not to be resold, distributed, or used by any other person. I fully accept the responsibility in using cannabis and I certify I fully understand the potential risks related to the use of cannabis products. If I start using cannabis, I agree to tell my physician if I experience any one or more of the following: Start to feel sad or have crying spells Have changes in my normal sleep patterns Lose my appetite Become more irritable than usual Become unusually tired Withdraw from my family and friends Lose interest in your usual activities In the event that I experience a severe adverse reaction, I am advised to immediately contact my physician. In the event that my physician is not available, I agree to call 911 for help, lie down and relax until help arrives. I agree to tell my physician if I have ever had symptoms of schizophrenia, bipolar disorder, psychotic episodes or attempted suicide. I also agree to tell my medical professional if I have ever been prescribed or taken medicine for any of these problems. I acknowledge that the risks of using cannabis under these circumstances could be severe. I understand that my physician does not suggest nor condone that I cease treatment of medications that stabilize my mental or physical condition. I am not pregnant, intending to become pregnant, or breastfeeding. I certify that I have read this document and declare that the information contained herein is true, correct and complete. Patient Signature: Date: 7.

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